MRCP Part-1 Preparation

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 Must-Read Notes of

Endocrinology

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 • Subacute thyroiditis causes hyper- then hypothyroidism
• Graves' disease may present first or become worse during the post-natal period
• Insulinoma is diagnosed with supervised prolonged fasting.
• The overnight dexamethasone suppression test is the best test to diagnosis Cushing's syndrome
• Diabetes mellitus - HbA1c of 6.5% or greater is now diagnostic
• Prolactin release is persistently inhibited by dopamine
• The PTH level in primary hyperparathyroidism may be normal
• Sudden onset headache + vomiting + neck stiffness + bitemporal superior quadratic defect + 3rd nerve palsy +
hypotension hypoaldernlaism is = pituitary apoplexy
• Pituitary Apoplexy Diagnosed by : MRI pituitary
• Treatment of pituitary apoplexy is = hydrocortisone IV to prevent Addisonian crisis.
• PPH + electrolytes disturbance (sodium 130 + high K + low TSH ) is = Sheehan syndrome
• Investigations in Sheehan syndrome are :
• MRI pituitary, pituitary function test LH/FSH
• Anterior hypopituitarism is differentiate from secondary hypothyroidism is by presence weight loss in anterior
hypopituitarism not in Secondary hypothyroidism

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 • High calcium + low phosphate + high ALP is = Primary Hyperparathyroidism
• Low calcium + high phosphate + Normal ALP is = Hypoparathyroidism
• Normal calcium +Normal Phosphate + normal ALP is = Osteoporosis
• High Calcium + high Phosphate + high ALP is = Bone metastasis
• Autoimmunity associated with Graves disease are:
• Vertilgo most common, Other DM type 1,Addison's Disease, Pernicious anaemia and Sjogren
• Low IQ + short stature + obesity + short 4th and 5th metacarpal + brachymetacarpals + calcification of nodules + round face +
sticky habitus + dental hypovolemic alright osteodystrophy is Pseudohypoparathyroidism
• Amiodarone use + no underlying thyroid disease + no goitre + decrease blood flow on Doppler + minimal or none iodine -131
uptake + markedly high iL-6 is = Amiodarone induced thyrotoxicosis type 2
• Treatment of Amiodarone induced thyrotoxicosis type 2 is : Withdrawal of Amiodarone and steroids.
• Amiodarone use + underlying thyroid disease like graves + Goitre + high blood flow on Doppler + normal or high iodine uptake+
low iL-6 is = Amiodarone induced thyrotoxicosis type 1
• Treatment of Amiodarone induced thyrotoxicosis type 1 is:
• Carbimazole, potassium perchlorate or lithium carbonate.
• Amiodarone induced hypothyroidism is not serious doesn't need treatment

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• Markedely high testosterone is androgen secreting tumour not PCOS
• Hirsutism + acne + high libido + testosterone 8.9(N <2.9) is = Androgen secreting tumour Key here testosterone more than 3 times upper limit
of normal
• Climotromegaly mainly with high androgen
• High testosterone + normal DHEA = ovarian source
• Normal testosterone + high DHEA is = Adrenal source
• Obesity - NICE bariatric referral cut-offs with risk factors (T2DM, BP etc.): > 35 kg/m^2 no risk factors: > 40 kg/m^2
• Patents on long-term steroids should have their doses doubled during intercurrent illness.
• A normal short synacthen test does not exclude adrenocortical insufficiency due to pituitary failure.
• HRT: adding a progestogen increases the risk of breast cancer.
• Riedel's thyroiditis is associated with retroperitoneal fibrosis.
• Bilateral idiopathic adrenal hyperplasia is the most common cause of primary hyperaldosteronism
• Thinning of pubic and axillary hair is seen in females with Addison's disease due to reduced production of testosterones from the adrenal gland
• Thyrotoxicosis with tender goitre = subacute (De Quervain's) thyroiditis
• Radioactive iodine uptake (RAI 131 scan)In graves = high homogeneous diffuse uptake
• Toxic nodular goitre = patchy uptake or solitary area of high uptake
• De Quervain thyroiditis = no uptake or reduced uptake

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 • Side effects of Exogenous androgens are :
• Acne, Gynaecomastia, Hypertension, Hypercholesterolemia, Hepatic tumours, Paranoid delusions
• Yellowish hue (Carotinemia)+ obesity + bradycardia + hypothermia + coma + non compliant to treatment + hair thinning +
perioribital edema is = Myxoedema coma
• Treatment of myxoedema coma is initial IV thyroid hormone T3 levothyroxine with IV hydrocortisone to avoid Addisonian
crisis Rewarm slowly
• Inferity loss of libido galtorrhoe(low GNRH )+ delayed growth hypoglycaemia (low GH ) + secondary hypothyroidism (low
TSH) + secondary adrenal insufficiency (low ACTH )= pan hypopituitarism
• treatment of panhypopitutarism is: 1st hormone to loss is GNRH 1st hormone to replace is hydrocortisone
• Young women + 10 weeks post partum is unwell with maladies sweats tiredness anxiety + high T3,T4 low TSH positive
anti TPO is = Postpartum thyroiditis
• Treatment of propranolol not Carbimazole
• 4 to 6 Month after delivery + hyper then hypothyroidism + anti- TPO antibodies + destructive lymphocytic thyroiditis is =
postpartum thyroiditis
• Polyuria + peptic ulceration/constipation/Pancreatitis + bone fracture + hypertension + renal stones + High calcium + low
phosphate + high PTH or normal is = primary hyperparathyroidism

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• Investigation in Kallman's syndrome: Diagnostic test is FISH MRI = absent olfactory bulbs, Low testosterone and low FSH LH
• Treatment of Kallman's Syndrome is:
• Pulses not continuous GnRH, Once family is completed then testosterone.
• Klinefilters syndrome = Low testosterone + raised LH and FSH,
• Kallman’s Syndrome = Low testosterone + Low FSH and LH.
• Primary hypogondasim ( Klinefilters syndrome ) = High LH + Low testosterone.
• Hypogondotrophic hypogondasim (Kallman’s Syndrome ) = Low LH and FSH + Low testosterone.
• Androgen insensitivity syndrome = High LH + Normal / High testosterone.
• Testosterone secreting tumour = Low LH + High testosterone.
• thyrotoxicosis + goitre + Autoantibodies + thyroid eye disease is = Graves disease.
• 5 hypo’s in Addison’s disease: Hypotension (postural), Hypoglycaemia, Hyponatremia, Hypo aldosterone, HypoPH
• 2 HYPER in Addison’s disease: Hyperkalaemia, Hyperreninemia .
• Patient of Addison’s disease who undertaken strenuous activity should double their dose of glucocorticoid and mineralocorticoids.
• lethargy , weakness + anorexia + nausea , vomiting + weight loss + hyperpigmentation at palmer or buccal mucosa + loss of pubic
hairs + hypotension + high K + Low sodium is = Addison’s disease
• treatment of Addison’s disease is: Hydrocortisone 100 mg IV TDS, Fludrocortisone for postural drop

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 • Low ACTH + no skin pigmentation + no hyperkalaemia + BP normal + low Cortisol + normal aldosterone is = Secondary
hypoadrenalsim
• Treatment of Secondary hypoadrenalsim is : Only glucocorticoid.
• Cortisol curve can be used to asses how appropriate dosing of glucocorticoid steroids in Addison patient
• Expothalmus + diplopia + conjunctival oedema + optic disc swelling + opthalmoplegia + inability to close eye lids lid lag lid
retraction + eu,hypo,hyperthyroid is = Thyroid eye disease.
• Management of Thyroid eye disease is: Stop smoking, Stop Radioiodine, Use topical lubricant, High dose steroids, Orbital
decompression, In replased or active disease = Radiotherapy, Malignant exophthalmos = Steroids
• Investigation in Insulinoma are: Supervised , prolonged fasting (up to 72 hours), CT pancreases 90%are less than 2cm in size.
• High insulin + high C peptide + high pro-insulin + normal SU level = Insulinoma
• High insulin + high C peptide + high SU level is = sulphonylurea overdose
• High insulin + low C peptide = Exogenous insulin or insulin misuse
• Low insulin + low C peptide is = non beta cell tumour
• Causes of hypoglycaemia less than 60mg/dl are: Insulinoma,nSelf administration insulin/ sulphonylurea, Liver failure,
Alcohol, Addison disease.

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• In Addison’s disease there is low T4 and high TSH so never treat thyroid problems treat Addison’s thyroid will become normal .
• treatment of thyroid overdose is: Propranolol, Plasmaphresis in severe cases, Cholestrayamine.
• Investigation in Addison disease: ACTH stimulation test(short synacthen test) After giving synacthen of 250ug normally there
increase cortisol of greater than 550 if below this confirm diagnose of adrenal insufficiency to dx localize it we do long synacthen
test where if cortisol raise then it's secondary adrenal insufficiency if not then it's Primary.
• Other tests in Addison’s diseases: Adrenal autoantibodies anti21 hydroxylase Ab, 9am cortisol and ACTH test low Cortisol and high
ACTH, Metabolic acidosis, Macrocytic anaemia pernious, Blood: high Eosinophila,lymphocytosis, neutropenia mild Hypercalcemia.
• Causes of Addison’s diseases: Autoimmune (most common)Infections TB = do CT abdomen showing shrinkage of adrenals, HIV,
CMV, Antiphospholipid syndrome (Hughes syndrome), Waterhouse fried ache syndrome Metastasis (bronchial breast kidney)
• Female patient with history of recurrent DVT and confirmed hypoaldostrone low sodium high K positive short synacthen test is =
Antiphospholipid syndrome ( Hughes syndrome)
• Sepsis / surgery/ steroid withdrawal/infection + hypotension + hypothermia + syncope + convulsions + Hyponatremia +
hyperkalaemia + hypoglycaemia is = Addisonian crisis
• Treatment of Addisonian crisis is = IV fluids IL normal saline and steroids IV hydrocortisone 100mg of IV Dexamethasone
• Tiredness Lethargy + postural Hypotension + high ESR + DIC + purpura + Hyponatremia high K is = Waterhouse fridirch syndrome
• Treatment of Waterhouse fridrich syndrome is = IV fluids and IV hydrocortisone

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 • T scores > -1 =Normal, T score b/w -1 to -2.5 =osteopenia, T score less than -2.5=osteoporosis
• Cerebral oedema is an important complication of fluid resuscitation in DKA, especially in young patents.
• Graves' disease is the most common cause of thyrotoxicosis
• High oestrogen + high progesterone + low LH,FSH + high prolactin + high Beta HCG is = pregnancy
• Normal oestrogen + high testosterone + LH high + FSH normal + high FSH and LH ratio is = Polycystic Ovarian syndrome.
• Low oestrogen + high FSH,LH is = Premature ovarian failure
• Treatment is: hormone replacement.
• Normal oestrogen + high FSH and LH is = resistant ovary Syndrome.
• Elevated LH and testosterone with normal FSH = Polycystic Ovarian syndrome.
• Testosterone >7 + Hirutism + virilisation + deep voice + ciltromegaly is = Adrenal or ovarian tumour.
• Tall + lack of secondary sexual characteristics + Gynaecomastia + low testosterone + high LH FSH + firm small tests is = Klinefilters
syndrome
• Investigation in Klinefilters syndrome are: Low testosterone, High LH FSH, Karyotype 47,XXY,47XX, Low HDL cholesterol, high TGA,
Most appropriate test is FSH LH level.
• Treatment of Klinefilters syndrome is Testosterone to improve bone minerization
• Anosmia + delayed puberty + low Testosterone, low FSH,LH + normal height + Cryptorchidism + hearing defects/cleft lip plate visual
defect + primary amenorrhea + no mental retardation is = Kallman's syndrome

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 • Gliflozins - SGLT2 inhibitors
• Orlistat works by inhibiting gastric and pancreatic lipase to reduce the digestion of fat
• Gitelman's syndrome: normotension, hypokalaemia + hypocalciuria
• Hashimoto's thyroiditis is associated with thyroid lymphoma
• Glitazones are agonists of PPAR-gamma receptors, reducing peripheral insulin resistance
• HRT: adding a progestogen increases the risk of breast cancer
• Infertility in PCOS - clomifene is superior to metformin
• Thiazides cause hypercalcaemia
• Serum IGF-1 levels are now the first-line test for acromegaly
• The short synacthen test is the best test to diagnose Addison's disease
• A 10 g monofilament should be used to assess for diabetic neuropathy in the feet
• Hypoglycaemia in patients with alcoholic liver disease does not respond to glucagon
• In Cushing's disease, cortisol is not suppressed by low-dose dexamethasone but is suppressed by high-dose
dexamethasone
• Non-functioning pituitary tumours present with hypopituitarism and pressure effects

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 • Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines
• Klinefelter's - LH & FSH raised Kallman's - LH & FSH low-normal
• Prolactin - under continuous inhibition
• LH surge causes ovulation
• HRT: unopposed oestrogen increases risk of endometrial cancer
• Exenatide causes vomiting
• Thyrotoxicosis with tender goitre = subacute (De Quervain's) thyroiditis
• Myxoedemic coma is treated with thyroxine and hydrocortisone
• Bilateral idiopathic adrenal hyperplasia is the most common cause of primary hyperaldosteronism
• Klinefelter's - 47, XXY
• Polycystic ovarian syndrome - ovarian cysts are the most consistent feature
• A normal short synacthen test does not exclude adrenocortical insufficiency due to pituitary failure
• Cervical cancer: Human papillomavirus infection (particularly 16,18 & 33) is by far the most important risk factor
• Glucocorticoid treatment can induce neutrophilia
• Klinefelter's syndrome - elevated gonadotrophin levels

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 • Sulfonylureas often cause weight gain
• Patients with type I diabetes and a BMI > 25 should be considered for metformin in addition to insulin
• During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after
sunset
• Thinning of pubic and axillary hair is seen in females with Addison's disease due to reduced production of testosterones from
the adrenal gland
• Riedel's thyroiditis is associated with retroperitoneal fibrosis
• Meglitinides - bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
• Graves' disease is the most common cause of thyrotoxicosis
• Pioglitazone - contraindicated by: heart failure
• SGLT-2 inhibitors work by increasing urinary excretion of glucose (Important as it is the cause of main side effects - increased
urine output, weight loss, UTI)
• Thyrotoxic storm is treated with beta blockers, propylthiouracil and hydrocortisone
• Small cell lung cancer accounts 50-75% of case of ectopic ACTH
• Excessive flatulence is an extremely common side effect of acarbose which is often poorly tolerated

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 • Anaplastic thyroid cancer - aggressive, difficult to treat and often causes pressure symptoms
• In sulphonylurea overdoses, patients are at risk of recurrent hypoglycaemia
• Exenatide = Glucagon-like peptide-1 (GLP-1) mimetic
• Diabetes diagnosis: fasting > 7.0, random > 11.1 - if asymptomatic need two readings
• Meglitinides - stimulate insulin release - good for erratic lifestyle
• 9 am cortisol between 100-500nmol/l is inconclusive and requires further investigation with a short synacthen test
• Gitelman's syndrome is due to a reabsorptive defect of the NaCl symporter in the DCT
• Acromegaly is caused by excessive growth hormone. Somatostatin directly inhibits the release of growth hormone, and
hence somatostatin analogues are used to treat acromegaly
• Subacute thyroiditis causes hyper- then hypothyroidism
• Acromegaly: increased sweating is caused by sweat gland hypertrophy
• Sulfonylureas - bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
• Sulfonyureas increase stimulation of insulin secretion by pancreatic B-cells and decrease hepatic clearance of insulin
• The overnight dexamethasone suppression test is the best test to diagnosis Cushing's syndrome
• The PTH level in primary hyperparathyroidism may be normal

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 • Cerebral oedema is an important complication of fluid resuscitation in DKA, especially in young patients
• HPV vaccination should be offered to men who have sex with men under the age of 45 to protect against anal, throat and
penile cancers
• Octreotide can be used as an adjunct to surgery in patients with acromegaly
• Hashimoto's thyroiditis = hypothyroidism + goitre + anti-TPO
• Systemic glucocorticoids can cause drug-induced acne. This is characterised as monomorphic papular rash without
comedones or cysts. This does not respond to acne treatment but improves on drug discontinuation
• Mirabegron is a beta-3 agonist
• Causes of raised prolactin - the p's
• pregnancy
• prolactinoma
• physiological
• polycystic ovarian syndrome
• primary hypothyroidism
• phenothiazines, metoclopramide, domperidone

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 • Bartter's syndrome is associated with normotension
• First line treatment in diabetic neuropathy is with amitriptyline, duloxetine, gabapentin or pregabalin
• Anticholinergics for urge incontinence are associated with confusion in elderly people - mirabegron is a
preferable alternative
• Klinefelter's? - do a karyotype
• Cushing's syndrome - hypokalaemic metabolic alkalosis
• Carbimazole blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin
→ reducing thyroid hormone production
• In type 1 diabetics, a general HbA1c target of 48 mmol/mol (6.5%) should be used
• Pioglitazone may cause fluid retention
• PHaeochromocytoma - give PHenoxybenzamine before beta-blockers
• Patients with acromegaly have an increased risk of colorectal carcinoma

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 • Iron reduces the absorption of thyroxine
• Medullary thyroid cancer, phaeochromocytoma, marfanoid body habitus - multiple endocrine neoplasia type IIb
• Patients on long-term steroids should have their doses doubled during intercurrent illness
• Diabetes mellitus - HbA1c of 48 mmol/mol (6.5%) or greater is now diagnostic (WHO 2011)
• Metformin is the first line therapy of choice for diabetes in pregnancy
• Peptic ulceration, galactorrhoea, hypercalcaemia - multiple endocrine neoplasia type I
• Oxybutynin should not be used in frail older women with urinary incontinence due to the risk of impairment of
daily functioning, confusion and acute delirium
• Graves' disease may present first or become worse during the post-natal period
• Gliptins = Dipeptidyl peptidase-4 (DPP-4) inhibitors
• Addison's disease is associated with a metabolic acidosis
• Congenital adrenal hyperplasia is most commonly due to 21-hydroxylase deficiency
• Insulinoma is diagnosed with supervised prolonged fasting
• Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria

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